UNMC News

Half of Nebraska's hospitals have joined coalition; member hospitals and board members listed

When choosing a health care facility, the executive director of the Nebraska Coalition for Patient Safety said potential patients should add one more query to their list of questions: “Do you self-report adverse events?”

And if the answer is “no,” Ann McGowan said, maybe you should consider getting your knee replacement – or whatever it may be – somewhere else.

Its aim is to create a culture of safety in Nebraska health care by encouraging, assisting and collaborating in the self-reporting of medical errors and patient-safety events by health care organizations across the state. The reports are then studied, and de-identified and shared across NCPS membership, in hope of avoiding a repeat of similar incidents.

“By sharing this information with others, hospitals can learn to prevent errors before they happen,” said Stephen Smith, M.D., NCPS president and chief medical officer at The Nebraska Medical Center.

According to its 2012 annual report, NCPS has trained more than 250 professionals from 59 health care organizations in the use of root-cause analysis – a tool to analyze and learn from adverse events.

Half of Nebraska’s hospitals have joined the coalition – but half have not. It’s tough to crack the culture of keeping our mistakes to ourselves, said Darwin Brown, assistant professor in UNMC’s physician assistant education program, who serves as NCPS treasurer.

But those incidents are happening, whether the public hears about them or not. A 2008 U.S. Department of Health and Human Services report found that 13.5 percent of Medicare beneficiaries surveyed experienced a serious adverse event during their hospital stay. An additional 13.5 percent experienced smaller events which resulted in temporary harm.

If we hear of an incident, we may be less apt to use that hospital. “But I tend to think the opposite,” McGowan said. “It means they’re engaged. They know what’s going on.”

We all make mistakes – even health care organizations.

There’s only one way to find out if a health care organization is learning from its mistakes, McGowan said: Ask.